Families of Children with Attention Deficit

Hyperactivity Disorder: A Review

Lily Hechtman, MD, FRCPC1

Objectives: 1) To review the evidence of attention deficit hyperactivity disorder (ADHD) and other conditions in
family members (siblings and parents) of children with ADHD and determine the importance of genetic and
environmental factors in this condition. 2) To describe the prospective 10-year follow-up of 65 families with ADHD
children and 43 families of matched normal controls. 3) To review various studies that have looked at parent–child
interactions with ADHD children on and off stimulant medication, and such interactions over time. The paper thus
provides an overview of family pathology and functioning of families of ADHD children over time.
Method: The paper outlines twin, sibling, family and adoption studies with regard to possible genetic and
environmental factors in ADHD. It also presents data of a prospective 10-year follow-up of 65 families with ADHD
children and 43 families of normal controls. This family study evaluated sociocultural factors, child rearing
practices, health of family members and relationships, as well as the parental view of the child’s functioning over
time.
Results: A review of the literature suggests that ADHD has a strong genetic component, but that environmental
factors also play an important role. Families of children with ADHD have more problems than families of normal
controls, but these problems improve as the child with ADHD grows up and leaves home. Families of ADHD
subjects can appreciate positive as well as negative changes in their children over time. Generally, family
interactions with children with ADHD are problematic but improve when the child is on medication and when the
child becomes an adult.
Conclusions: This condition has strong genetic underpinnings; therefore, diagnosing and treating family members
(parents and siblings) as well as the child with ADHD is important in improving parent–child interactions and
better long-term outcome for the child and his or her family.

(Can J Psychiatry 1996;41:350–360)

Key Words: ADHD, families, genetics, follow-up

T his paper addresses the area of families of children with

ADHD in 3 distinct ways. First, it reviews the evidence
of ADHD and other conditions in family members (siblings
and parents) of children with ADHD and determines the
importance of genetic and environmental factors in this con-
dition. Second, it describes the prospective 10-year follow-up
of 65 families with ADHD children and 43 families of
matched normal control children. Third, the paper reviews
various studies that have looked at parent–child interactions
Manuscript received January 1996, revised June 1996.
1
Director of Research, Division of Child Psychiatry, Professor of Pediatrics
and Psychiatry, McGill University; Director of Adolescent Services and
Staff Psychiatrist, Montreal Children’s Hospital, Montreal, Quebec.
Address reprint requests to: Lily Hechtman, Department of Psychiatry,
Montreal Children’s Hospital, 4018 Ste Catherine Street West, Montreal,
QC H3Z 1P2
Can J Psychiatry, Vol 41, August 1996
350
with ADHD children on and off stimulant medication, and
such interactions over time.
The paper thus provides an overview of family pathology
and functioning of families of ADHD children over time.
Families and the Evidence of Genetic Factors in ADHD
This section will review twin, sibling, family and adoption
studies in relation to children with ADHD to evaluate the
evidence presented in these studies for a genetic basis in this
condition. Wherever possible, the relative importance of
genetic and/or environmental factors (see Tables I–IV) will
be presented, because often the 2 factors act together in
producing symptoms and impairment.
Studies involving siblings and parents of children with
ADHD are important from an etiological perspective in that
they suggest possible genetic underpinnings in this condition.
They are also important from a treatment perspective,
however, in that awareness of the genetic factors in ADHD
August 1996 Families of Children with ADHD 351

Table I
Evidence of Genetic Factors in ADHD: Twin Studies
Number of
Authors Subjects Results Critique Conclusions
Lopez (1965) MZ - 4 pairs − MZ more concordant than DZ for ADHD - Small number - None possible
DZ - 6 pairs − 4 of DZ opposite-sex pairs
Heffron (1984) MZ - 3 pairs − All concordant for ADHD - Small number − None possible
− No comparisons
Goodman and MZ - 29 pairs − All 13 years − Sufficient number − 50% genetic
Stevenson (1989) DZ - 45 pairs − MZ more alike regarding ADHD symptoms − Looked at genetic and − 50% environmental
than same-sex DZ environmental factors
− Environmental factors operating, eg,
perinatal and family adversity
Gillis and others MZ - 81 pairs − MZ 81% concordant for ADHD − All twins also reading disabled − ADHD is hereditary
(1992); Gilger and DZ - 52 pairs − DZ 29% concordant for ADHD − Statistical regression model used
others (1992)
Stevenson (1992) MZ - 91 pairs − MZ more similar in measures of activity and − Symptoms, not diagnosis, − Genetic factors in attention and
DZ - 105 pairs attention than DZ measured activity
Edelbrock and MZ - 99 pairs − MZ correlations of 0.68, DZ 0.29 for − Wide age range of 4 to 15 years − Genetic factors in attentional
others (1995) DZ - 82 pairs attentional problems − Used only CBCL problems and school competence
− Genetic factors in competence in school and − Multiple regression analysis − Envionmental factors in social
behavioural problems functioning, anxiety, and
− Environmental factors in participation in depression
social relationships, school performance,
anxiety, depression, delinquency

will make clinicians more vigilant about detecting, diagnos-
ing, and treating the condition in siblings and parents. Such
diagnosis and treatment will hopefully improve family func-
tioning and parent–child interaction and result in better treat-
ment outcome for children with ADHD.
Twin Studies
Generally, genetically based disorders should be very
similar in twins and more similar in monozygotic (MZ)
(identical) than in dizygotic (DZ) (fraternal) twins. Recently,
there have been a number of twin studies that have looked at
the concordance of ADHD in twins.
An early study by Lopez (1) compared 4 pairs of MZ males
with 6 pairs of DZ twins. Four of the DZ twins, however, were
opposite-sex pairs in which the male was hyperactive. This
limits the validity of the study. Another small study by
Heffron and others (2) reported on 3 pairs of MZ twins, all
concordant for ADHD.
More recently, Goodman and Stevenson (3) studied 570
thirteen-year-old twins. These authors focused particular at-
tention on 29 MZ and 45 DZ same-sex twin pairs in which at
least one twin met criteria for pervasive hyperactivity (that is,
hyperactivity present in all situations, such as at home and at
school). MZ twins were more alike than same-sex DZ pairs
on objective measures of attentiveness and on parent and
teacher ratings of hyperactivity (59% versus 33%). In their
careful study, the authors also explored the possible effects
of stereotyping (that is, the tendency to rate identical twins
similarly), adverse family factors (for example, marital
discord, parental criticism, and malaise), and perinatal adver-
sity (for example, low birth weight). They concluded that
genetic effects accounted for approximately one-half of the
explainable causes of hyperactivity and inattentiveness, leav-
ing up to about 50% to be explained by other causes, including
environmental aspects.
In their extensive study of reading-disabled twins in the
Colorado Reading Project, Gillis and others (4) and Gilger
and others (5) attempted to diagnose ADHD in the twins by
parental responses on the Diagnostic Interview of Children
and Adolescents (DICA) (6). They thus examined 81 MZ and
52 same-sex DZ pairs of a reading-disabled sample of twins.
They found that for reading disability, the concordance rate
was 84% for MZ twins and 66% for DZ twins. For ADHD,
the concordance rate was 81% for MZ twins and 29% for DZ
twins. The concordance rate for both reading disability and
ADHD was 44% for MZ twins and 30% for DZ twins. The
data suggest that both reading disability and ADHD may have
strong though independent genetic components (5).
Gillis and others (4) examined the same group of subjects
but focused particularly on 37 MZ and 37 DZ same-sex twin
pairs of whom one twin had been diagnosed with ADHD via
the DICA. The authors used a basic regression model for
analysis (a statistical technique) and found that 79% of MZ
twins and 32% of DZ twins were concordant for ADHD
(P < 0.001). Furthermore, adjustment for IQ or reading
performance differences did not substantially change their
results. The authors thus conclude that the results of this
analysis suggest that ADHD is highly heritable.
352 The Canadian Journal of Psychiatry Vol 41, No 6

Table II
Sibling Studies
Authors Number of Subjects Results
Safer (1973) − 19 full-sibling pairs − 50% (10/19) full siblings
− 22 half-sibling pairs concordant for ADHD
− 9% (2/22) half-sibling pairs
concordant for ADHD
Borland and Heckman − 22 hyperactive subjects − Mean age of 30
(1976) − 20 brothers − Hyperactive subjects have
more emotional and work
problems than brothers
Feldman and others (1978) − 48 hyperactive subjects − Mean age of 21
− 48 siblings − Hyperactive subjects have
more educational, emotional,
and social problems
Loney and others (1983) − 22 hyperactive subjects − Age 21 to 23
− 22 brothers − Hyperactive subjects worse
than brothers in work, social,
and antisocial measures, but
brothers worse than normal
controls
Welner and others (1977) − 53 siblings of − 26% brothers of hyperactive
hyperactive subjects subjects had ADHD
− 38 siblings of controls − 9% brothers of controls had
ADHD
Faraone and others (1993) − 140 ADHD − ADHD and their siblings have
− 120 controls more school failure and lower
− 303 siblings of ADHD IQ than normal controls and
and others their siblings
Critique
− 20- to 25-year retrospective
diagnosis
− 10- to 12-year retrospective
diagnosis
− Siblings may not be of the
same sex
− Retrospective diagnosis
− Normal controls
− National survey, other studies
not matched or evaluated
directly
− No environmental measures
Conclusions
− Genetic factors appear
important
− As adults, hyperactive
subjects worse than
brothers
− No genetic implications
− As adults, hyperactive
subjects worse than
siblings
− No genetic implications
− Hyperactive subjects worse
than brothers
− Brothers worse than normal
controls
− Not clear if genetic or
environmental factors
− Siblings of hyperactive
subjects worse than
siblings of controls
− Suggest genetic factors as
matched for SES and IQ
− ADHD may be genetic

One of the largest twin studies is currently being carried
out in Australia (7). The authors plan to screen 3 400 four- to
twelve-year-old twin pairs and their siblings and determine
the perinatal and developmental history, as well as the inci-
dence and concordance of ADHD, conduct disorder (CD),
and separation anxiety (SA). The study is ongoing and the
results are not yet available.
Various studies have suggested that different symptoms of
ADHD are heritable. In an early study, Rutter and others (8)
reported that monozygotic twin pairs were more similar to
one another than dizygotic twins in psychomotor activity.
This finding was confirmed by Willerman (9) and Torgensen
and Kringlen (10).
Stevenson (11), using multiple regression analysis (a sta-
tistical technique) on data obtained from 91 pairs of MZ twins
and 105 pairs of same-sex DZ twins, concluded that results
were consistent with a significant genetic contribution to
individual differences in activity level and attention abilities.
Recently, Edelbrock and others (12) evaluated 99 MZ and
82 same-sex DZ pairs of twins aged 4 to 15 years via the Child
Behavior Checklist (CBCL) completed by parents. They
found a correlation of 0.68 (MZ) and 0.29 (DZ) for attentional
problems. Generally, using multiple regression analysis, they
found significant genetic influences on competence in school
and on all areas of problem behaviour. Significant shared
environmental influences were detected for participation in
activities, quality of social relationship, performance in
school, anxiety and depression, and delinquent behaviour.
Thus, these twin studies also indicate a greater concor-
dance in monozygotic than dizygotic twins for different
components of the syndrome. This supports the hypothesis
that there is a genetic component in this condition.
Sibling Studies
Most studies involving siblings of hyperactive subjects
have used the siblings as a control or comparison group. In
such studies, hyperactive children usually functioned worse
than their siblings. Thus, Borland and Heckman (13), in a 20-
to 25-year retrospective study, interviewed 20 men (mean age
30) who, from childhood medical records, conformed to the
diagnostic criteria for hyperactive child syndrome. The
authors compared this group with their brothers (mean age
28). Generally, they found that neither the hyperactive sub-
jects nor their brothers experienced serious social or psychi-
atric problems as adults. The hyperactive subjects, however,
had more emotional and work difficulties and lower socio-
economic status.
Feldman and others (14) also carried out a 10- to 12-year
retrospective follow-up study on 48 young adults (mean age
21) previously diagnosed as hyperactive and compared them
August 1996 Families of Children with ADHD 353

Authors
Morrison and Stewart (1971)
Cantwell (1972)
Frick and others (1991)
Biederman and others (1990,
1992)
Faraone and others (1994)
Number of Subjects
− Parents of 59 hyperactive
subjects
− Parents of 48 controls
− Parents of 50 hyperactive
subjects
− Parents of 50 controls
− Biological relatives of 177
children with ADHD or CD
− 457 fist-degree relatives of
73 children with ADD, 26
children other conditions,
26 normal controls
− Second-degree relatives of
140 children with ADHD,
120 normal controls
Table III
Family Studies
Results
− 20% of hyperactive subjects
had a parent who was
hyperactive as a child
vs 5 % of controls
− 21% of hyperactive subjects
had a parent who was
hyperactive as a child vs
2% of controls
− Relatives of children with
ADHD increased childhood
history of ADHD
− 25% of relatives of ADD
children had ADD vs 5% of
those with other conditions
vs 4.6% of normal controls
− Relatives of children with
ADHD increased risk for
ADHD compared with
second-degree relatives of
normal controls
Critique
− Retrospective diagnosis of
parents via parental reports
− Retrospective diagnosis of
parents via parental reports
− Retrospective diagnosis via
report of a relative
− Direct structured interview
evaluations
− Diagnosis of relatives made
by interview of parents
Conclusions
− Increased rate of
hyperactive subjects in
parents of hyperactive
subjects
− Increased rate of
hyperactive subjects in
parents of hyperactive
subjects
− Increased rate of ADHD in
biological relatives of
children with ADHD
− Increased rate of ADD in
first-degree relatives of
children with ADD
− Increased risk of ADHD in
second-degree relatives of
children with ADHD
− Greatest risk for biological
relative of ADHD parent

with their siblings. Ninety-one percent of individuals with the
diagnosis of hyperactivity at age 21 were either in school or
working. When compared with their siblings, however, the
hyperactive subjects had lower educational achievement and
lower self-esteem. Some 10% of the individuals with hyper-
activity seemed to have significant problems with respect to
drug use, inactivity, and schizoid personality disorders. Ten
percent of the hyperactive subjects drank alcohol before work
or school compared to none of the sibling controls. Again,
one gets the picture that siblings of hyperactive subjects are
functioning fairly well and better than the hyperactive indi-
viduals.
In Loney and others’ study (15), she compared 22 pairs of
hyperactive individuals and their brothers, age 21 to 23 years.
Again, there is a clear pattern that hyperactive subjects do
worse than their siblings in a variety of areas; for example,
more hyperactive subjects have significant unemployment,
impaired interpersonal relationships, and a lack of permanent
residence when compared to their brothers. Thus, 45% of the
hyperactive individuals meet antisocial outcomes criteria
(modified by excluding Impaired Interpersonal Relation-
ships) compared with 18% of the brothers and 6% of the
normal control subjects in an extensive depression study.
Even though there was no significant difference in the number
of hyperactive subjects and their brothers who were diag-
nosed as definitely and probably alcoholic (27% and 23%,
respectively), this finding is greater than that of a depression
study, where only about 9% of the controls met alcoholic
criteria.
There was also no significant difference with regard to
nonmedical drug use between hyperactive subjects and their
brothers, but both groups differed from the National Survey
on Drug Abuse norms. This difference was greater for the
hyperactive subjects who used more inhalants (glue, cocaine,
sedatives, and stimulants) than was the norm in the national
survey. There was a trend for the sibling group to use more
stimulants than the national survey group. Hyperactive
subjects were more involved in crimes against persons, and
this involvement tended to be more severe when compared to
that of their brothers. Consequently, the hyperactive subjects
had more serious police involvement, with 41% having been
convicted or having spent time in jail compared to 5% of their
brothers. We thus see that though the hyperactive subjects are
not functioning as well as their brothers, the brothers in turn
are not functioning as well as a normal control group; they
have more antisocial personality disorder and more alcoholism.
A study comparing siblings of 53 hyperactive subjects
with siblings of 38 matched control subjects was carried out
by Welner and others (16). They matched a group of hyper-
active subjects and a group of control subjects on sex (all
males), race (all white), age (mean age 11 years), and socio-
economic status (roughly middle class). All had IQs of 79 or
above, were free of significant neurological abnormalities
and psychosis, and were living with their mother. Welner and
others then compared all the siblings of both groups (hyper-
active and controlled) age 6 and older. They found that 26%
of the brothers of hyperactive subjects but only 9% of brothers
of control subjects (P < 0.02) had ADHD. In addition, bro-
thers of the hyperactive subjects had 3 or more depres-
sion–anxiety symptoms. Again, no differences were found in
the sisters. Interestingly, no differences were found in antiso-
cial behaviour in the brothers and sisters of hyperactive and
control subjects, though hyperactive subjects themselves
showed more antisocial behaviour.
354
More recently, Faraone and others (17) compared psychi-
atric and intellectual assessments of 140 children with ADHD
and 120 normal controls with their 303 siblings. The probands
generally were white, non-Hispanic boys. Not surprisingly,
the ADHD children were more likely to have had learning
disabilities, repeated grades, been placed in special classes,
and received academic tutoring. They also performed worse
on the Wechsler Intelligence Scale for Children-Revised
(WISC-R). For these ADHD children, comorbid conditions
such as conduct disorder, major depression, and anxiety dis-
order predicted school placement more than school failure or
WISC-R scores. This comorbidity, however, was not the
main factor as ADHD children without comorbidity had more
school failure and lower WISC-R scores than normal
controls. Intellectual impairment and school difficulties were
also increased among the siblings of ADHD children.
Faraone concludes that this finding lends support to the
hypothesis that ADHD syndrome is familial.
In another early study, Safer (18) compared the incidence
of ADHD in 19 full- and 22 half-sibling pairs. Each pair had
been raised together by a common mother. One member of
this pair was known to have minimal brain dysfunction
(MBD), now known as ADHD. Nearly half (10) of the
full-sibling pairs were concordant for ADHD compared to
only 2 of the 22 half-sibling pairs. This significant difference
between full and half siblings further supports a genetic
component of this condition.
In summary, siblings (particularly brothers) of hyperactive
subjects function better than the hyperactive subjects but
seem to have more problems than siblings of controls (for
example, higher rates of hyperactivity and more
depression–anxiety symptoms), although not more antisocial
behaviour. It remains unclear if these difficulties reflect
familial patterns, genetic influence, or merely the stress of
having a same-sex hyperactive sibling. When taken together
Authors Number of Subjects
Morrison and − Adoptive parents of 35
Stewart (1973) adopted children with
hyperactivity
Alberts-Corush and − Biological adoptive relatives
others (1986) of 43 children with ADHD
Cadoret and − N = 283 adoptees aged
Stewart (1991) 18 to 40
− Group 1 = Biological parent
with psychiatric or
behavioural problems
− Group 2 = Biological parent
with no psychiatric or
behavioural problems
The Canadian Journal of Psychiatry Vol 41, No 6
with the much stronger genetic evidence from the twin studies
(described previously), sibling studies add further support to
the presence of genetic factors in ADHD.
Parental Studies
Family studies of hyperactive children have been based on
the assumption that a genetic component to hyperactivity will
be reflected in a higher familial rate of the disorder for
children with ADHD.
Thus, in an early study, Morrison and Stewart (19) found
that 20% of hyperactive children in their study had a parent
who was diagnosed (retrospectively) as hyperactive, com-
pared with 5% of their medical controls. Similarly, Cantwell
(20) also found that 21% of hyperactive boys in his sample
also had a parent who could be classified as being hyperac-
tive–antisocial in childhood versus 2% of the pediatric clinic
controls.
More recently, Frick and others (21) assessed the history
of childhood behaviour problems in the biological relatives
of 177 outpatient boys, aged 7 to 12 years with ADHD or
conduct disorder (CD). The mothers, fathers, and other bio-
logical relatives of children with ADHD were significantly
more likely to have a history of childhood ADHD but no
antisocial behaviour problems or substance use in childhood.
Attention deficit disorder with or without hyperactivity was
similarly associated with a family history of ADHD.
In a series of studies by Biederman and others (22,23)
(described in detail later), the authors found that first-degree
relatives of ADHD children had higher risks for ADHD
compared with relatives of other psychiatrically referred chil-
dren and relatives of pediatric clinic controls (25.1% versus
5.3% versus 4.6%, P < 0.00001), respectively.
Faraone and others (24) expanded these investigations and
explored the prevalence of ADHD in second-degree relatives
Table IV
Adoption Studies
Results Critique Conclusions
− Adoptive parents less likely to have been − Retrospective diagnosis − Biological parents of
hyperactive in childhood than biological from parental reports hyperactive subjects more
parents − No comparison group often hyperactive than
adoptive parents,
therefore genetic
factors supported
− Biological relatives do worse on measures − Factors such as IQ and − Some support for genetic
of attention than do adoptive relatives of SES not controlled for factors in ADHD
ADHD children
− Biological parent’s disorder predicted − Biological and
antisocial personality disorder in adult environmental factors,
adoptees only if placed in lower SES home both important
− Lower SES: no increase in antisocial
personality disorder without biological
parent having criminality/delinquency
− Psychiatric problems in adoptive parents
increased aggressivity in adoptees
August 1996 Families of Children with ADHD
of 140 ADHD children and 120 normal controls. The infor-
mation was collected from the subjects’ parents.
This assessment process has obvious limitations, however
the authors found that the second-degree relatives of ADHD
children were at increased risk for ADHD compared with the
second-degree relatives of normal control children. These
risks were greatest when the second-degree relatives were
biologically related to an ADHD parent of an ADHD child.
Consistent with the greater prevalence of ADHD among boys
compared with girls, grandfathers were at greater risk than
grandmothers, and uncles at greater risk than aunts. The
authors thus advocate the usefulness in obtaining information
from second-degree relatives in evaluating the genetic
epidemiology of ADHD, as such studies would clarify the
mechanism of familial transmission.
Adoption Studies
The possible genetic basis of this condition is further
supported by the finding that adoptive relatives of ADHD
children are less likely to have ADHD or associated disorders
than are biological relatives of such children (25). In addition,
biological relatives of ADHD children perform worse on
standardized measures of attention than do adoptive relatives
of ADHD children (26).
Other Conditions in Families of Children with ADHD
In addition to increased rates of ADHD in families of
hyperactive children, other conditions have also been found
with some frequency in these families. Thus, Morrison and
Stewart (19) and Cantwell (20) found that biological parents
of hyperactive children had higher rates of “sociopathy, hys-
teria, and alcoholism compared to parents of normal con-
trols.” Morrison (27) also found a higher incidence of
unipolar but not bipolar affective disorder in the combined
second- degree blood relatives of hyperactive children. Re-
cently, McCormick (28) found that depression in mothers of
children with ADHD was significantly higher than that found
in primary care outpatients. Specifically, an incidence of
17.9% for major depression and 20.5% for minor depression
was found in mothers of children with ADHD, compared with
4% to 6% and 6% to 14%, respectively, for primary care
outpatients.
The most extensive family studies to date have been car-
ried out by Biederman and his colleagues (22,23). In the first
of these studies (22), they compared 73 male ADD probands
and 264 of their first-degree relatives to 26 psychiatrically
referred but not ADD children, 101 of their first-degree
relatives, 26 normal pediatric clinic controls, and 92 of their
first-degree relatives. The authors used blinded interviewers,
structured psychiatric interviews, and controlled for gender,
generation of relative, age of proband, social status, and
intactness of the family. Relatives of ADD probands had
higher morbidity risks for ADD (25.1% versus 5% versus
4.6%, P < 0.00001), antisocial disorders (24.3% versus 6.9%
versus 4.2%, P < 0.00001), and mood disorders (27.1% versus
13.9% versus 3.6%) than did relatives of psychiatric and
355
normal controls. These findings indicated the importance of
family–genetic risk factors in ADD. In a more recent similar
expanded study (23) of 140 probands, 120 normal controls,
and 822 of their first-degree relatives, Biederman showed
nearly half (49%) of the ADHD subjects had no comorbidity
with conduct disorder, major depressive or multiple anxiety
disorder. Compared to controls, however, ADHD probands
were more likely to have these conditions. Similarly, relatives
of ADHD probands had a higher risk for ADHD (25% versus
8%), antisocial disorders, major depressive disorders (26%
versus 9%), substance dependence, and anxiety disorders.
Biederman suggests ADHD and major depressive disorders
may show common familial vulnerabilities, that ADHD and
conduct disorder may be a distinct subtype, and that ADHD
and anxiety disorder are transmitted independently in fami-
lies. He concludes that these results extend previous findings,
indicating family–genetic influences.
Early family studies did not clearly distinguish between
purely hyperactive children and those who had hyperactivity
or ADHD combined with conduct disorder and/or opposi-
tional disorder. Recent studies which looked at this comor-
bidity suggest that children with these combined diagnoses
may have significantly different family patterns than children
who have only ADHD.
Biederman and his colleagues (29) evaluated first-degree
relatives of 22 children with ADHD and 29 normal controls.
Fourteen (64%) of the ADHD children also had the diagnosis
of conduct or oppositional disorder. Relatives of this group
of children had significantly more antisocial disorder, oppo-
sitional disorder, antisocial personality disorder, nonbipolar
depressive disorder, and overanxious disorder compared with
relatives of normal controls and hyperactive subjects without
coexisting conduct or oppositional disorder. Relatives of
ADHD children, with and without conduct or oppositional
disorder, did not differ in their high rates of ADHD (34%
respectively). This was significantly higher than the rate of
ADHD in relatives of normal controls. Interestingly, the
incidence of drug and alcohol abuse and dependence did not
differ significantly in the 3 groups.
Lahey and others (30) also compared parental pathology
in children (6 to 13 years of age) with conduct disorder (N =
37), with ADHD (N = 18), and with both disorders. Parents
of children with conduct disorder were more likely to abuse
substances. Mothers of conduct-disordered children were
more often depressed and more frequently had the triad of
antisocial personality disorder, substance abuse, and somati-
zation disorder. In contrast, parents of children with ADHD
only did not have any significant disorders; however, fathers
of children with both conduct disorder and ADHD were more
likely to have a history of aggression, arrest, and imprison-
ment.
Barkley and others (31,32), in their 8-year follow-up of
hyperactive children, also collected information on the bio-
logical fathers of these children. They found that fathers of
356 The Canadian Journal of Psychiatry
hyperactive children compared with fathers of normal
controls had a history of significantly more antisocial acts,
alcohol abuse, police contacts, and arrests. Their job histories
were less stable and they were generally less financially
responsible. The authors concluded that 11% of fathers of
hyperactive children met DSM-III-R criteria for antisocial
personality disorder as opposed to 1.6% of fathers of normal
control children (P < 0.05). When the authors examined the
antisocial acts of fathers of children with hyperactivity, with
and without associated conduct disorder, they found that the
fathers of children with hyperactivity and conduct disorder
had more antisocial acts than those with hyperactivity alone.
Fathers of children who were only hyperactive, however, still
had more antisocial acts than fathers of normal controls.
These studies clearly suggest that the combination of ADHD
and conduct disorder is associated with significant parental
pathology.
The possible connections between parental pathology,
childhood ADHD, and its adult outcome were explored in a
recent study by Cadoret and Stewart (33). The authors studied
283 adoptees, age 18 to 40. The adoptees were divided into
2 groups based on whether or not biological parents showed
evidence (from adoption agency records) of psychiatric prob-
lems or behavioural disturbance. In addition to evaluation of
biological parents from agency records, direct evaluation of
adoptees and adoptive parents was also carried out. The
authors found that the biological parents’ criminality or
delinquency predicted increased antisocial personality disor-
der in adult adoptees only when the adoptee had been placed
in a lower socioeconomic-status (SES) home. The lower SES
home had no effect on development of adult antisocial per-
sonality disorder when there was no criminality in the bio-
logical background.
The importance of the environmental factors was also seen
in the fact that psychiatric problems in the adoptive home
were associated with aggressivity syndrome, and lower SES
of the adoptive home increased the incidence of ADHD
syndrome. Aggressivity but not ADHD predicted antisocial
personality disorder in adult adoptees.
This study demonstrates the importance of genetic (bio-
logical parental pathology) and environmental (SES and
pathology of adoptive family) factors in the development of
adult antisocial personality disorder.
Long-Term Follow-Up of Families of Hyperactive
Children
Hechtman (34) compared 65 families of hyperactive
young adult subjects and 43 families of control subjects
matched for socioeconomic status. The mean age of the
hyperactive and control subjects at this 10-year follow-up
period was 19 years. In addition to the socioeconomic factors,
areas such as child-rearing practices, physical and mental
health of family members, and family relationships were
assessed. The families of hyperactive subjects had had similar
Vol 41, No 6
assessments initially and at 5-year follow-up. The authors
thus had an opportunity to evaluate if and how families had
changed in these areas with time, and whether these changes
had any relationship to the hyperactive subjects’ functioning.
This sequential evaluation of families of hyperactive subjects
constituted a second part of their study.
Finally, the parents’ view of their children’s functioning
at different ages in their development was assessed.
Subjects
Sixty-five families of hyperactive subjects being assessed
in a 10-year follow-up study (mean age 19) were compared
with 43 families of normal control subjects matched with the
hyperactive subjects for age (range 17 to 24 years), sex, IQ
(all above 85), and socioeconomic status (each group having
equal representation from each status).
Structured family interviews by blinded interviewers and
various scales assessing the families and the families’ assess-
ment of their child at various ages were completed by the
interviewers and the families.
Results
Current Assessment of Families of Hyperactive and
Control Subjects at 10-Year Follow-Up
Sociocultural Factors. In view of the fact that both groups
were matched for socioeconomic status (each group having
an equal representation from each status), most of the
sociocultural factors reflecting socioeconomic status were, as
expected, not significantly different for the families of hyper-
active and control youngsters. The groups did not differ in
other social factors such as family size, incidence of adoption,
or being born from a previous marriage. With respect to
sibling order, hyperactive children were significantly more
frequently the eldest (P = 0.01).
Child-Rearing Practices. Of the child-rearing parameters
assessed, including inconsistency, lack of controls, and puni-
tive–authoritative and overprotective styles, only the puni-
tive–authoritative parameter tended to be more marked in
families of hyperactive subjects (P = 0.07).
Health of Family Members. There was no difference in the
prevalence of physical illness or deaths in the 2 groups of
families, but parents of hyperactive children tended to have
more mental health problems (P = 0.06). Unfortunately, the
types of mental health problems that prevailed were not
specifically categorized. The severity was categorized on a
5-point scale. “Severe” referred to any condition that required
psychiatric hospitalization, psychotic conditions, character
disorders with multiple offenses, or drug addiction including
alcoholism. “Mild” referred to any neurotic condition.
Seven of 41 (17%) families of control children received
psychiatric treatment compared with 18 of 65 (28%) families
of hyperactive children. When we examined the history of
psychiatric symptoms in family members who received no
treatment, however, we saw that 10 of 41 (24%) control
August 1996 Families of Children with ADHD
families had such symptoms compared with 27 of 65 (41%)
hyperactive families. We thus see that the striking difference
in the mental health of family members between the 2 groups
was not due to a history of severe psychiatric pathology,
which requires treatment, but a reflection of milder symp-
toms, which usually go untreated. Finally, a significantly
higher proportion of parents of control versus hyperactive
children showed good dynamic integration (P = 0.05).
Relationships. Marital relationships also tended to be
worse in families of hyperactive children (P = 0.09). The
2 most significant findings indicated that the emotional cli-
mate of the home (P = 0.009) and the overall family score
(P = 0.004) were considerably worse in families of hyperac-
tive children when compared with those of control children.
The emotional climate of the home was defined as the degree
of positive versus negative interactions among family mem-
bers (for example, arguments or quiet talks) giving rise to a
general level of tension or tranquillity.
Sequential Evaluation of Families of Hyperactive Subjects
Sociocultural Parameters. There appeared to be little
change in factors reflecting socioeconomic status during the
3 assessment periods. Parents’ education and work status
changed little, although, as one would expect, more mothers
were working at the 10-year follow-up period.
Child-Rearing Practices. Child-rearing practices re-
mained the same over the 3 periods, except for a less
punitive–authoritative approach at the 10-year follow-up.
Health of Family Members. Families had experienced
more medical illnesses and deaths at 10-year follow-up than
at the time of the initial assessment or 5-year follow-up,
however the mental health of family members had improved
by the time of the 10-year follow-up. This had been observed
already 5 years earlier, but was not yet significant at that time.
Relationships. Emotional climate of the home, marital
relationship, and total family score were not significantly
different at the 3 assessments. When we analyzed those
families where the hyperactive subjects were no longer at
home, however, we saw that at 5-year follow-up (mean age
13) the emotional climate at home was considerably worse at
the initial assessment (mean age 8) or at 10-year follow-up
(mean age 19), even though the marital relationship remained
unchanged. This suggests that the emotional climate of the
home improved when the hyperactive young adult left.
In summary, families of hyperactive children had more
difficulties than those of normal controls. These difficulties
were mainly in the areas of mental health of family members,
marital relationships, and, most particularly, the emotional
climate of the home. The families also tended to use a more
punitive–authoritative child-rearing approach. In the sequen-
tial evaluation of families, however, we saw that this punitive
child-rearing tendency decreased at the 10-year follow-up.
The mental health of family members also improved at the
10-year follow-up, as did the emotional climate in the home;
357
the latter only if the hyperactive subject had moved out.
Generally, families of hyperactive subjects tended to improve
in their functioning with time, even though they did not equal
the functioning of families of matched controls.
Parental View of Child’s Functioning Over Time. Even
though families of hyperactive children see their offspring as
having more difficulties currently than control children, they
are on the whole not more pessimistic about their present or
future functioning. Conflicts that remain appear tolerable to
both families and the hyperactive young adult. Finally, fami-
lies of hyperactive subjects can, despite many problems with
their children, still appreciate shifts in both their achieve-
ments and difficulties at each developmental stage. In view
of the above findings, more concentrated work with the
families of hyperactive children as part of the comprehensive
treatment of this condition seems highly recommended.
Parent–Child Interactions
In the previous section, we discussed how parents of
children with ADHD often have significant mental health
problems characterized by higher rates of ADHD, depression,
antisocial personality disorder, and/or substance abuse. These
parental difficulties are often associated with multiple prob-
lems in their ADHD children (for example, comorbidities
such as oppositional defiant disorder, conduct disorder, de-
pression, and anxiety). It is therefore not surprising that the
parent–child interactions of ADHD children and their parents
would be problematic.
Thus, Battle and Lacey (35) showed that mothers of highly
active males were critical, disapproving, unaffectionate, and
severe in their punishment. This was particularly true in the
middle-childhood years. None of these maternal behaviours
were associated with high activity levels in females.
There have been several studies which have supported the
view that mothers of hyperactive children are merely re-
sponding to the type of behaviour and difficulties that their
children present and do not cause these problems. Campbell
(36) compared observational data of 3 groups of mothers and
children while performing easy and difficult tasks. The 3
groups represented reflective, impulsive, and hyperactive
children. The authors found no differences in the
mother–child interactions among the groups during the easy
task. During the difficult task, however, mothers of hyperac-
tive children made more encouraging comments and pro-
vided more suggestions concerning impulse control. There
was a trend for mothers of the hyperactive children to be more
disapproving, but this was not significant. Generally, mothers
of hyperactive children were seen as supportive and not
punitive. As no differences in mother–child interactions
existed between the groups during the easy task, the authors
concluded that the mothers of hyperactive children were
responding to the child and adopting a more controlling style
as the child experienced more difficulty.
358 The Canadian Journal of Psychiatry
In a subsequent study (37) that compared the interactions
of hyperactive, learning-disabled, and matched normal boys
and their mothers on the same easy and difficult tasks, the
results were similar. Mothers of hyperactive childen provided
more encouragement, impulse-control directions, and disap-
proval when compared to the mothers of the other 2 groups.
Again, the authors concluded that mothers were responding
to the child’s behaviour.
Humphries and others (38) hypothesized that stimulant
medication which modified children’s behaviour would in
turn change mothers’ interactions with their children—that
is, make them more positive and less controlling. This would
also support the idea that mothers were primarily responding
to their children’s hyperactivity. The authors gave hyperac-
tive children and their mothers a highly structured task to
perform together under both drug and placebo conditions.
Unlike in Campbell’s studies (36,37) where the mother’s
participation was optional, in Humphries’ studies (38), her
participation was mandatory. While on medication, hyperac-
tive children and their mothers made fewer errors, praised
each other more, and criticized each other less, and mothers
gave fewer directions. This change in the nature of the
mother–child interaction, while the child was on stimulants,
led the authors to conclude that mother’s intrusive, control-
ling, disapproving pattern was a response to the child’s dis-
ordered behaviour and not a cause of it, since it modified with
changes in the child’s behaviour. Humphries, however, did
not have a control group with which the hyperactive
mother–child dyad could be compared, so the degree of
normalization achieved by stimulant medication could not be
assessed. In addition, the authors used a very structured
laboratory test which may not be relevant to real-life
situations.
Both of these shortcomings were addressed and controlled
by Cunningham and Barkley (39). These authors compared
the interactions of hyperactive (off medication) and normal
boys and their mothers in both free play and task settings.
They found that during free play, mothers of hyperactive
children interacted less with their children. They initiated
fewer contacts, responded less, and encouraged play less.
When they did interact, they tended to be more controlling,
but the children also complied less. In the task setting, again
mothers of hyperactive children initiated fewer contacts and
responded less than mothers of control subjects. Mothers of
hyperactive children were more controlling and gave more
commands, but even though the children complied less, their
mothers rewarded compliance less and tended to be inconsis-
tent in rewarding desired behaviours. The authors concluded
that the intrusive, controlling style of the mothers of hyper-
active boys, while initially a response to the child’s overac-
tive, impulsive, inattentive style, may further contribute to the
child’s behavioural difficulties.
These findings were almost identical to those of Mash and
Johnston (40), who also compared mother–child interactions
in younger and older hyperactive children (off medication)
Vol 41, No 6
and an age-matched control group in structured-task and
free-play situations. The mothers of hyperactive subjects
were more directive and negative, and less responsive and
approving. This was particularly true for the mothers of the
younger hyperactive children in the structured-task situation.
In a subsequent study, Barkley and Cunningham (41)
compared mother–child interactions of hyperactive children
in both drug and placebo states. When the hyperactive chil-
dren were on drugs, they increased their compliance, and their
mothers reduced their commands, and increased their respon-
siveness. However, the level of responsiveness and interac-
tion between the mothers and their hyperactive sons did not
equal that of the normal control children. Schachar and others
(42) also showed that when the hyperactive child is medi-
cated, the mothers show increased warmth, increased contact,
and decreased criticism, and the hyperactive child relates
better to siblings and peers.
The fact that mothers of hyperactive children may get
locked into a negative parenting pattern, which extends to
nonhyperactive siblings, was pointed out by Mash and
Johnston (unpublished observations). The authors compared
interactions of hyperactive children, their siblings, and their
mothers with those of age-matched normal control children.
Results showed that hyperactive children and their siblings
had more social conflict and higher rates of negative behav-
iour during play. The conflicts decreased during the mother-
supervised situations. Mothers of hyperactive children were
less responsive, interactive, and rewarding, and more nega-
tive than mothers of nonhyperactive children. This was true
of their interactions with the siblings as well as the hyperac-
tive children.
Few studies have looked at the parenting style of fathers
of hyperactive children. Tallmadge and Barkley (43) found
that fathers of hyperactive children, like mothers, were more
directive than fathers of control children; however, the hyper-
active children were more likely to comply with fathers’ than
with mothers’ commands.
It is thus not surprising that Mash and Johnston (44) found
that parents of hyperactive children reported less confidence
in their parenting knowledge when compared to control chil-
dren. In addition, mothers of hyperactive children reported
more stress, social isolation, self-blame, and depression. This
finding was similar to the increased personal psychological
distress reported by mothers of hyperactive adolescents ver-
sus mothers of normal control subjects who were seen by
Barkley in their 8-year prospective follow-up study (32).
Interactions Over Time
A number of authors have looked at parent–child interac-
tions of hyperactive subjects over time. Campbell and Ewing
(45) compared interactions from early to late childhood, and
Barkley and others (32) compared them from childhood to
adolescence. Generally, the authors concluded that findings
with older hyperactive children were less negative and that
older children were able to sustain compliance better than
August 1996 Families of Children with ADHD
younger ones. As seen in Barkley and others’ (32) adolescent
follow-up study, however, the interactions, even with older
hyperactive subjects, are still more problematic when com-
pared to those of normal control subjects. Observations of
mother–adolescent interactions in Barkley’s study found that
the hyperactive dyad displayed more negative and controlling
behaviours and less positive and facilitating behaviours to-
ward each other than the normal dyad. These interaction
patterns were significantly related to similar patterns in
mother–child interactions observed 8 years earlier. These
difficulties were particularly prominent in situations where
the adolescent had ADHD and oppositional defiant disorder
(ODD). The authors suggest that the development and
maintenance of ODD into adolescence in hyperactive chil-
dren is strongly associated with aggression and negative
parent–child interactions in childhood.
Generally, one can conclude that the controlling, less
responsive, and more negative parenting style of mothers of
hyperactive children, reported in several studies, is most
probably a consequence and not a cause of the child’s behav-
iour. It is thus also not an intrinsic, predetermined aspect of
the mother’s personality. The evidence that the parenting
style became markedly more positive (less controlling, and
intrusive, and more rewarding) when the child’s behaviour
improved on stimulant medication shows that it is the child’s
behaviour which initially influences the mother’s behaviour.
However, even with stimulant medication, the mother–child
interaction of hyperactive children, though much improved,
does not equal that of normal control children. It seems that
old habits and patterns, once established, are modifiable but
difficult to alter entirely; therefore, even if the negative
mother–child interaction seen in hyperactive children is in-
itially a response to the child’s overactive, impulsive, inatten-
tive style, it may affect the child’s future development in
terms of self-esteem and social competence and thus exacer-
bate his or her handicaps and symptomatology. Interventions
(parental counselling, parent training groups) that would fos-
ter appropriate parenting skills in parents of hyperactive
children are therefore crucial.
Summary and Conclusions
In summary, one can see that siblings of hyperactive
children fare better than the hyperactive children, but worse
than normal control children. The parents of hyperactive
children are more often hyperactive, antisocial, and depressed
when compared to parents of normal control children. Fur-
thermore, the mental health of family members improves with
time, particularly if the hyperactive youngster leaves home.
Interactions of hyperactive children with their parents and
siblings are more negative but improve on medication, al-
though, even on medication, they do not equal those of normal
control children. Finally, the family studies described in this
paper have significant etiological and treatment implications.
Specifically, from the etiological point of view, there is much
evidence for a familial (genetic) basis for this condition. With
359
regard to treatment, it seems clear that treatment needs to be
comprehensive. Comprehensive treatment needs to include
medicating the child, treating affected parents, and providing
parent training and counselling in order to ensure more posi-
tive clinical and long-term outcome for these hyperactive
children and their families.
Clinical Implications
• Possible genetic factors in ADHD.
• Affected parents and siblings should be assessed and treated.
• Long-term outcome may improve with better mental health of
family members.
Limitations
• Specific genetic difficulty not determined.
• Parents and siblings may decline treatment.
• Other factors also affect long-term outcome.
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Résumé

Objectifs : 1) Examiner les données relatives au trouble d’hyperactivité avec déficit de l’attention (THADA) et à
d’autres affections chez les membres de la famille (fratrie et parents) d’enfants atteints de THADA et déterminer
l’importance des facteurs génétiques et environnementaux dans le cadre de cette affection. 2) Décrire le suivi
prospectif sur 10 ans de 65 familles d’enfants atteints de THADA et de 43 familles de témoins normaux appariés.
3) Examiner diverses études portant sur les interactions parents-enfants chez des enfants atteints de THADA qui
recevaient périodiquement des stimulants et sur ces interactions au fil du temps. L’article donne donc un aperçu
de la pathologie familiale et du fonctionnement des familles d’enfants atteints de THADA en fonction du temps.
Méthode : L’article décrit des études sur les jumeaux, la fratrie, la famille et l’adoption à l’égard des facteurs
environnementaux et génétiques éventuels du THADA. On y présente aussi les données d’un suivi prospectif sur
10 ans de 65 familles d’enfants atteints de THADA et de 43 familles de témoins normaux. Cette étude familiale a
évalué les facteurs socioculturels, les pratiques d’éducation des enfants, la santé des membres de la famille et
leurs relations mutuelles, ainsi que la perception par les parents du fonctionnement de l’enfant en fonction du
temps.
Résultats : Un examen de la littérature révèle que le THADA comporte une importante composante génétique,
mais que les facteurs environnementaux jouent également un rôle important. Les familles d’enfants atteints de
THADA éprouvent davantage de problèmes que les familles des témoins normaux, mais ces problèmes s’atténuent
au fil de la croissance de l’enfant atteint de THADA et lorsqu’il quitte le domicile familial. Les familles des sujets
atteints de THADA peuvent constater des modifications positives ou négatives chez les enfants en fonction du
temps. En général, les interactions entre les familles et les enfants atteints de THADA sont marquées par des
problèmes, mais elles s’améliorent lorsque l’enfant reçoit des médicaments et lorsqu’il devient adulte.
Conclusion : Cette affection a de profondes ramifications génétiques : par conséquent, le diagnostic et le
traitement des membres de la famille (parents et fratrie), de même que de l’enfant atteint de THADA, sont
importants afin d’améliorer les interactions parents-enfants et les résultats à long terme pour l’enfant et sa famille.